Genius for strokes

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Bundled payments and dual-eligibles bring opportunities to long-term care operators, experts say
Bundled payments and dual-eligibles bring opportunities to long-term care operators, experts say
With more than 4 million stroke survivors in the United States, and roughly 40% of them requiring specialized care for at least moderate impairment, it stands to reason that rehabilitation providers are working harder than ever to provide good service.

It is a long-term care resident stream that does not figure to be soon diminished.

Determining the best therapy approach isn't easy because each stroke incident, degree of impairment, rate of recovery and overall outcome is as unique as the residents themselves. Treatment approaches, too, are anything but one-size-fits-all. The good news is an ever-growing array of stroke-recovery therapies and supplemental — and, in some cases, experimental — practices are allowing therapists to add some new and promising treatment approaches to their arsenal.

“We know that the brain has a remarkable ability to regain lost function, and we also know that the route each person can take toward recovery can be very different. What works for one person might not provide the same result in another, and the goals and priorities will also differ from one person to the next, which is why therapy must be tailored to each individual,” says Jan Davis, MS, OTR/L, president and founder of International Clinical Educators Inc. She's also the spokeswoman for the American Occupational Therapy Association on issues related to stroke rehabilitation.

One thing that does apply to virtually every stroke recovery patient is that the sooner treatment begins, the better. Not only does early and aggressive intervention give the greatest opportunity for maximum functional recovery, experts agree that it also helps reduce the risk for other potentially debilitating and even life-threatening conditions.

“Patients who have suffered a stroke are usually at increased risk for development of multiple comorbidities,” notes Mary Van de Kamp, senior vice president of clinical operations for RehabCare Inc. Those conditions include pressure ulcers, dehydration, malnutrition, deep vein thrombosis, seizures and falls. Muscle atrophy and depression can compound matters further, she notes.

“With medical intervention advancements, we as rehabilitation professionals are now able to intervene with patients much [earlier] in the recovery process,” Van de Kamp adds. She notes that patients who just five to 10 years ago might have languished in a hospital bed for eight to 10 days before receiving any meaningful rehabilitation are now coming to the skilled nursing facility around five to seven days post-stroke.

No pause for recovery
Attitudes and perceptions surrounding stroke recovery also have evolved, which has further contributed to faster, more targeted therapy for even the most compromised patients.

“Stroke patients are now treated more aggressively rather than with kid gloves. They are pushed hard to recover function sooner,” says Dede Tsuruoka, OT, vice president of clinical services for Hallmark Rehabilitation LLC.

Experts largely agree that stroke recovery often hinges on the marriage of nursing services and physical, occupational and speech-language therapies. Ideally, the practitioners will work closely together (and alongside social workers and recreational therapists, as appropriate) to tailor a rehab program around the patient's personal interests, hobbies, daily routines, occupations and individual recovery goals.

While spontaneous recovery occurs quickly and statistics show that the window of opportunity for best post-stroke outcomes is within the first six months, it's common for stroke patients to experience alternating bouts of progress and plateaus, and a recovery process that can take years.

In light of the often-lengthy recovery — and therapy caps that limit treatments for some — therapists must work quickly and methodically to coordinate care and make the most of the therapy provided during a skilled stay.

More than ever, therapy is based on the principle of neuroplasticity, the brain's ability to adapt and relearn certain essential functions after stroke, often through the use of repetition and other techniques that engage and strengthen areas of the body and brain most affected by the stroke.

“It's up to us as clinicians in skilled nursing facilities to provide our patients with the most effective treatments in the short amount of time we have with them to achieve the best results,” says Megan Harper, PT, outpatient rehabilitation manager for Life Care Center of Littleton, a skilled nursing facility in Littleton, CO.

With such limitations in mind, experts stress that functional, relevant therapy that meets the fundamental needs of each individual — such as basic communication, mobility and the ability to perform some activities of daily living — is critical. For the many stroke recovery patients with speech or swallowing impairment, for example, a simple communication system that helps patients communicate hunger, thirst, pain or comfort will go a long way toward motivating and engaging them, and advancing their recovery, according to Martha Schram, president of Aegis Therapies.

“I can't overemphasize the need to keep therapy functional in accordance with the communication lifestyle the person is used to,” she says, noting that when patients can communicate their basic needs, their confidence and self-esteem improve, which helps motivate them to recapture an active lifestyle.

New communications
The way patients are communicating and engaging in therapy sessions has indeed evolved in recent years.

Increasingly, traditional neuromuscular re-education and neurodevelopmental techniques, such as the Bobath method and proprioceptive neuromuscular facilitation (PNF), are being blended with supplemental (and, in some cases, high-tech) treatment approaches to further advance therapy progress.

On the speech language pathology side, for example, newly emerging therapies, such as the Madison Oral Strengthening Therapeutic (MOST) device, an assistive intra-oral tool that provides resistance for tongue exercises that aid communication and swallowing, are showing progress.

Therapy approaches that tap into the brain's internal timing also are catching on in stroke therapy. At Cascade Park Care Center in Vancouver, WA, therapists are employing a computer-based system, called the Interactive Metronome, which uses an auditory guidance system that guides patients through a series of coordinated, repetitious and task-oriented movements, progressively challenging them to improve their timing by matching the computer's rhythm.

The community also uses a complementary intervention called Melodic Intonation Therapy, a type of “singing therapy” that uses melodic and rhythmic components to tap into undamaged areas of the brain and increase fluent production of speech.

“With these interventions, our stroke patients have made remarkable progress,” says Cascade speech language pathologist Cassandra Kimble, MS, CCC-SLP. One patient, she says, had such slurred speech at the beginning of treatment that caregivers were unable to understand her basic wants and needs. “Within a few months, she was able to speak with family members over the phone and computer.”

Brain tricks
Based on the assumption that the brain processes information better with a combination of sight, sound and touch, some therapists are also incorporating virtual reality technology, using sign language and VR to generate a synthesized voice in speech therapy sessions, and VR and repetitive movement to increase eye-hand coordination in OT/PT sessions.

“The idea is to create brain action whether the body moves or not. In this way, we begin to trick the brain into creating pathways to create movement,” says Kathleen Weissberg, MS, ORT/L, education director for Select Rehabilitation.

OT/PT therapy is increasingly incorporating functional electrical stimulation devices that mimic the signal that nerves usually send to arm and leg muscles, and work to facilitate movement in the hand and normalize gait patterns.

“New waveforms allow improved retraining of the brain, thus prompting the development of new motor pathways,” says Pat Hoskin, PT, TOPAZ director, Hallmark Rehabilitation.

And the benefits of the technology don't end there.

“We have taken advantage of electrical stimulation that can stimulate the muscles that support swallowing functions so often compromised in patients who have suffered a stroke. These methods of tricking the muscles into believing they are receiving neural signals are examples of the technologies that supplement the hands-on approaches of therapists at the bedside,” says Van de Kamp.

Still, electrical stimulation therapy isn't for everyone, including those with pacemakers.

Early ambulation is another big step forward in stroke rehab, thanks to the availability of body-weight supporting treadmill and track systems.

“The move is away from passive care to more active and challenging therapeutic approaches,” adds Life Care Center's Harper.

Low-tech, high impact  
 
While technology and supplemental rehabilitation tools have helped advance the field of stroke therapy and rehabilitation research, experts caution that high-tech approaches don't always translate into better outcomes.
 
Sensory-rich therapy environments filled with “normalized” experiences that work to rebuild motor skills through familiar actions and applications often deliver the best results, they say.

“There are many tools a therapist has at their disposal to facilitate muscle and nerve development,” notes Sharlaina Kramer, PT, Cascade Park Care Center. “Part of the challenge is finding activities that engage the patients' interests.”

Some of the most effective, engaging approaches often don't appear scientific or advanced. Therefore, they might have their value questioned by stroke-recovery patients and their families. But their benefits are very real, various experts assure.

“I've been in this profession for around three decades and I can tell you that some of the least scientific-seeming therapy approaches that engage the patient, that are meaningful for them and are taken from real-life are what work best,” Kramer says. “You don't need a robot or high-tech piece of equipment to help people regain function.”

Constraint-induced movement therapy (CIMT), which essentially works by restraining the functional arm to force use on the impaired side, is one relatively new and promising treatment approach in the area of stroke rehabilitation. The downside: CIMT requires patients to have some arm movement and some ability to move the hand, fingers and wrist, which means only a small percentage of stroke patients are good candidates.

That's not to say modified CIMT principles can't be applied on a broader scale, however. In speech therapy, for example, constraint refers to the avoidance of compensatory strategies, such as gesturing, drawing or writing, Weissberg explains, and “forced use” means communicating only by talking.

Simply working impaired limbs into therapy sessions and other activities also has been shown to speed recovery.

Davis never misses an opportunity to incorporate a weak (or even paralyzed) arm into therapy, for example — even if it just means placing an arm on the table instead of letting it drop to the side. She's also a staunch supporter of “guiding,” an easy-to-apply practice that has the therapist's or caregiver's hand guiding the patient's hand through various tasks — even before movement returns.

“This isn't a form of exercise,” she explains. “You place your hand over the patient's and then use your hand to power the movement in a comfortable, normal way.”

She notes that when the patient's hand is moved, such as with the action of hair brushing, the brain and neural impulses begin to kick into gear. Over time, and through repetition, notable progress is often made.

“Making a lunch, cutting up fruit or even brushing hair might not seem like big progress, but those everyday [tasks] are very important to a person who has had a stroke,” Davis reasons, adding that those seemingly small steps then pave the way for further progress and recovery.

“In therapy, people often want to latch on to that next big thing because they want that one answer that will give them better and faster results. There are some exciting advancements, but we need to remember that some of the least high-tech therapy approaches that mimic what patients do in real life are still the most effective.”
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